Many digestive problems seen in the pharmacy may be linked to dietary and lifestyle habits, as Victoria Goldman explains…

Digestive disorders affect most people from time to time, from an occasional bout of indigestion or constipation to long-term irritable bowel syndrome (IBS) or gastro-oesophageal reflux disease (GORD). Many mild to moderate conditions can be managed in primary care, often within the pharmacy setting.

“Community pharmacists tend to be reactive to what patients want to discuss about their healthcare needs,” says Alwyn Fortune, community pharmacist and RPS policy and engagement lead in Wales, “so customers may come into the pharmacy asking for advice specifically on their bloated feeling, stomach pain or diarrhoea.

“If pharmacies have relevant healthcare materials on show, such as leaflets about eating healthily, this may prompt a more general conversation about digestive health.”

Common digestive disorders

Around four in every 10 people in the UK experience indigestion (dyspepsia) at some point. This vague term describes discomfort in the upper part of the abdomen after a heavy, fatty or spicy meal. Heartburn and acid reflux affect up to one in every four UK adults.

Common symptoms include a burning feeling in the chest and an unpleasant sour taste in the mouth. GORD may be diagnosed in people with heartburn and indigestion for four weeks or more. It’s usually caused by a weak sphincter muscle at the bottom of the oesophagus.

Four out of 10 people experience occasional bloating. Bloating may occur more regularly in people with IBS or functional dyspepsia (indigestion with no specific cause).

Both functional dyspepsia and IBS are estimated to affect around one in five adults. These conditions are often linked and are thought to be due to a problem with the gut-brain interaction and oversensitivity of the digestive system.

Acute diarrhoea may be triggered by stress, taking certain medicines or a food intolerance. It may also be caused by food poisoning or gastroenteritis.

Acute constipation affects around one in seven otherwise healthy people and may be caused by lifestyle factors, such as a low-fibre intake, poor fluid intake or exercise.

Eating habits

Many digestive problems seen in the pharmacy setting may be linked to dietary and lifestyle habits. Eating too much, for example, can have a significant impact on digestive health.

“If someone is taking in too many calories for their needs and gaining weight above what is considered healthy, they may be at risk of heartburn and reflux, due to increased abdominal pressure,” says Julie Thompson, information manager at Guts UK charity.

“They may also be at risk of metabolic fatty liver disease (MAFLD). People who have a higher than healthy body weight can be at a higher risk of cancer over time, including bowel cancer, oesophageal cancer, pancreatic and gallbladder cancer.”

Eating too little can affect digestive health as well. “This is particularly evident in people with eating disorders, although they may not necessarily be underweight,” says Julie Thompson.

“People with anorexia nervosa can have problems with constipation due to inadequate food intake, plus IBS with constipation or IBS with mixed symptoms of constipation and diarrhoea. Functional dyspepsia can also be associated with eating disorders.”

Advice on maintaining good digestive health includes eating a healthy balanced diet, taking regular exercise, drinking plenty of fluids, avoid smoking and drinking alcohol within the recommended guidelines.

“Pharmacy-run stop smoking services or weight loss programmes may help customers with digestive problems,” says Alwyn Fortune. “Smoking can be a particularly bad for the gut and digestive health, leading to reflux or aggravating stomach ulcers or IBS.”

IBS management

IBS is the most common digestive disorder, causing abdominal pain and altered bowel habits. The most common treatments are diet and lifestyle changes, medicines to ease the symptoms, and counselling or psychotherapy.

A low-FODMAP (fermentable oligosaccharides, disaccharides, monosaccharides and polyols) diet is currently the most recommended diet. However, this can be highly restrictive and needs professional guidance.

“People with IBS should be referred to a specialist dietitian if elimination diets – for example, the low FODMAP diet – are to be considered,” says Julie Thompson.

“This is because of the risk of eating disorders in this population group. Elimination diets can be detrimental for people with eating disorders, and other IBS treatments should be considered in this situation. People with IBS shouldn’t be advised to try juicing diets or fasting as there’s no evidence that these diets are effective and there’s a potential that these can make symptoms worse.”

Other dietary advice focuses on a gluten-free diet or altering fibre intake. For many people with IBS, increasing soluble fibre, such as ispaghula, is more effective than eating more insoluble fibre, such as wheat bran. However, dietary advice for digestive problems needs to be patient specific.

“Increasing fibre may help one person with IBS but worsen symptoms in someone else,” says Alwyn Fortune. “I always ask about diet – whether they eat fatty foods or drink alcohol, eat late at night, have they noticed any trigger foods or meals, and are they drinking plenty of fluids. Having this conversation may help a patient work out what to increase or leave out.”

The medical treatment of IBS involves taking medicines to manage pain and ease any constipation or diarrhoea. This also needs to be patient specific. Although peppermint oil may help IBS pain, it can trigger other digestive symptoms such as heartburn or GORD. Probiotics may help to relieve bloating and other IBS symptoms but not in everyone.

“I concentrate on smooth muscle relaxants such as peppermint oil, hyoscine and mebeverine to alleviate pain,” says Alwyn Fortune. “Some people with diarrhoea or constipation may need something for those symptoms. However, they need to get the balance right, as taking a medicine for diarrhoea could lead to constipation.”

According to the results of the ATLANTIS trial published in The Lancet in October 2023, taking low-dose amitriptyline may improve IBS symptoms if first-line treatments aren’t effective. The study was conducted by Leeds, Southampton and Bristol Universities.

GPs prescribed low-dose amitriptyline, and patients managed their own dose based on the severity of their symptoms using a dose titration sheet.

“Anyone who has tried laxatives, antispasmodics, antidiarrhoeals, soluble fibre supplements, or first-line dietary changes but has ongoing symptoms should be considered for amitriptyline,” says Alexander Ford, professor of gastroenterology in the University of Leeds’s School of Medicine. “Amitriptyline is safe and well tolerated, provided the dose titration sheet is utilised. We have made this available on the ATLANTIS trial website. Patients shouldn’t go above the max dose (30 mg), without guidance from their GP.”

Guts UK/Falk Awards

The Guts UK/Dr Falk Awards 2024 awards close on February 12, 2024 at 5pm. The awards include a £1,000 prize for UK-based pharmacists working in gastroenterology in primary and secondary care who have developed programmes and initiatives to improve patient care.

For more information, visit https://gutscharity.org.uk/research/grants-and-awards/the-guts-uk-dr-falk-awards